A 28-year-old woman at 24 weeks of gestation with placenta previa presents with recurrent episodes of vaginal bleeding. She is hemodynamically stable and the fetus is alive. Regarding the complications and management of placenta previa, all of the following are correct EXCEPT:

Explanation

## Placenta Previa: Complications and Management Safety **Key Point:** Expectant management in placenta previa requires HOSPITALIZATION for monitoring, not outpatient home management. Recurrent bleeding episodes, even if currently controlled, carry unpredictable risk of massive hemorrhage. ### Why Hospitalization is Mandatory 1. **Unpredictable bleeding:** Placenta previa can hemorrhage suddenly without warning 2. **Rapid deterioration:** Massive bleeding can occur within minutes, requiring immediate access to blood products, OR, and cesarean delivery 3. **Fetal monitoring:** Continuous or frequent assessment needed to detect fetal compromise 4. **Immediate intervention:** If bleeding recurs, cesarean delivery may be needed urgently **Clinical Pearl:** Outpatient management is NOT safe for placenta previa at any gestational age. Even "stable" patients can decompensate rapidly. Some high-resource centers may consider selective outpatient follow-up in very selected cases (complete previa, no prior bleeding, >34 weeks), but this is NOT standard of care and carries significant risk. ## Placenta Accreta Spectrum (PAS) Disorder ### Risk Stratification | Risk Category | Relative Risk | Key Features | |---|---|---| | Placenta previa + 0 prior CS | ↑↑ | 3–5% risk of PAS | | Placenta previa + 1 prior CS | ↑↑↑ | 10–15% risk | | Placenta previa + ≥2 prior CS | ↑↑↑↑ | 25–50% risk | | Placenta previa + prior uterine curettage | ↑↑ | Endometrial scarring | **High-Yield:** The combination of placenta previa + prior cesarean delivery dramatically increases the risk of PAS disorder. This is one of the strongest associations in obstetrics. ## Maternal and Perinatal Outcomes ### Maternal Mortality - **Developed countries:** <1% (excellent blood bank access, ICU support, transfusion expertise) - **Developing countries:** 5–15% (limited resources) - **Major cause:** Massive hemorrhage requiring emergency hysterectomy ### Perinatal Morbidity and Mortality **Key Point:** Perinatal mortality remains substantial (5–15%) despite maternal survival, due to: - Preterm delivery (often <34 weeks) - Intrauterine growth restriction (IUGR) - Placental insufficiency - Iatrogenic prematurity from recurrent bleeding necessitating early delivery ## Antenatal Corticosteroid Administration ### Indications and Timing - **Gestational age 24–34 weeks:** Corticosteroids indicated to reduce respiratory distress syndrome, intraventricular hemorrhage, and neonatal mortality - **Regardless of bleeding status:** If preterm delivery is anticipated (which it is in placenta previa), steroids should be given - **Regimen:** Betamethasone 12 mg IM × 2 doses, 24 hours apart (or dexamethasone 6 mg IM × 4 doses, 12 hours apart) - **Repeat courses:** Considered in select cases if delivery not imminent and <34 weeks (individualized decision) **Clinical Pearl:** Antenatal corticosteroids do NOT increase infection risk or worsen bleeding in the context of placenta previa — they are protective for the fetus and should be given. ## Summary: Which Statement is WRONG? | Statement | Correct? | Reason | |---|---|---| | PAS disorder ↑ with previa + prior CS | ✓ | Well-established association | | Maternal mortality <1% in developed countries | ✓ | Accurate epidemiology | | Antenatal steroids at 24–34 weeks | ✓ | Standard of care | | Outpatient management safe in stable preterm patients | ✗ | Hospitalization is mandatory | **Warning:** Do NOT discharge a patient with placenta previa to home, even if "stable." The risk of sudden, life-threatening hemorrhage is too high.